Delirium Aims and Objectives - PowerPoint Presentation

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Slide2

Delirium

Aims and Objectives

The

overall aim of the session is for the trainee to gain an overview of delirium

By

the end of the sessions the trainee should:

Understand

the epidemiology, the risk factors associated and the basic physiological and psychological changes associated with delirium

Have

an understanding of the clinical features of delirium, and have a framework for the basic assessment process, principles of management, and prognosis.

Slide3

Delirium

To achieve this

Case Presentation

Journal Club

555 Presentation

Expert-Led Session

MCQs

Please sign the register and complete the

feedback

Slide4

Delirium

Expert Led Session

Delirium in the Elderly

Dr

Sadia Ahmed

Consultant Older Adult Psychiatrist

Slide5

Delirium

A neuropsychiatric syndrome (aka acute

confusional state or acute brain

failure)

that is common among the medically ill and often is misdiagnosed as a psychiatric illness which can result in delay of appropriate medical

intervention

There

is significantly mortality associated with delirium so identifying it is crucial!

Slide6

Clinical Features

Acute onsetUsually develops over hours to days

Onset may be

abrupt

Prodromal phase

Initial symptoms can be mild/transient if onset is more gradual

Fatigue/daytime somnolence

Decreased concentration

Irritability

Restlessness/anxiety

Mild cognitive

impairment

Slide7

Clinical Features

FluctuationUnpredictable

Over course of interview

Over course of 1 or more days

Intermittent

Often worse at night

Periods of

lucidity (m

ay

function at “normal”

level)

Psychomotor disturbance

Restless/agitated

Lethargic/inactive

Slide8

Clinical Features

Disturbance of consciousness

Hyperalert (overly sensitive to stimuli)

Alert (normal)

Lethargic (drowsy, but easily aroused)

Comatose (

unrousable

)

Inattention

Reduced ability to focus/sustain/shift attention

Easily distractible

External stimuli interfere with cognition

May account for all other cognitive deficits

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Clinical Features

Disruption of sleep and wakefulness

Fragmentation/disruption of sleep

Vivid dreams and nightmares

Difficulty distinguishing dreams from real perceptions

Somnolent daytime experiences are “dreamlike”

Emotional

disturbance

Fear

Anxiety

Depression

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Clinical Features

Disorders of thoughtAbnormalities in form and content of thinking are prominent

Impaired organization and utilization of information

Thinking may become bizarre or illogical

Content may be impoverished or psychotic

Delusions of persecution are common

Judgment and insight may be poor

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Clinical Features

Disorders of language

Slow and slurred speech

Word-finding difficulties

Difficulty with writing

Disorders

of memory and orientation

Poor registration

Impaired recent and remote memory

Confabulation can occur

Disorientation to time, place, and (sometimes)

person

Slide12

Three Types of Delirium

Hyperactive Delirium

T

he

patient is hyperactive, combative and uncooperative.

May appear to be responding to internal stimuli

Frequently these patients come to our attention because they are difficult to care for.

Slide13

Types of Delirium

Hypoactive

Delirium

Patient

appears to be napping

on/off

throughout the day

Unable to sustain attention when awakened, quickly falling back asleep

Misses meals, medications, appointments

Does not ask for care or attention

This type is easy to miss because caring for these patients is not problematic to staff

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Types of Delirium

Mixed

a combination of both types just described

The most common types are hypoactive and mixed accounting for approximately 80% of delirium cases

Slide15

Diagnosis

Confusion Assessment Method (CAM – 4 features)

Acute change in mental state with a fluctuating cause,

&

Inattention

plus

3. Disorganised Thinking,

or

4. Altered level of consciousness.

Sensitivity 94-100%

Specificity 90-95%

Slide16

Epidemiology of Delirium

Approximately

40

% of hospitalized elderly pts >65

years of age

50

% of pts post-hip fracture

30

% of pts in surgical intensive care units

20

% of pts on general medical wards

15

% of pts on general surgical wards

Slide17

Why does it matter?

After adjusting for age, gender, race,

pre-existing

comorbidity

&

cognitive

impairment,

diagnosis

and

s

everity of illness:

3 fold higher rate of death by 6 months

1.6 fold increase in ICU costs.

Longer hospital stays

Nearly 10x rate cognitive impairment on discharge.

1 in 3 survivors with delirium develop cognitive impairment.

Institutionalisation

Slide18

Dementia v Delirium

FEATURE

Delirium

Dementia

Onset

Acute

Usually insidious

Duration

Transient

Persistent

Course

Fluctuating over hours

Stable over days

Awareness

Depressed

Normal

Attention

Impaired

Relatively normal

Language

Incoherent, hesitant, slow or rapid

Anomia common

Perception

Frequent illusions & hallucinations

Normal early; agnosia, misidentification & hallucinations later

Thinking

Disorganised, delusional

Impoverished

Mood

Agitation or fear common

Apathy or disinhibition common

Psychomotor Changes

Common

Uncommon

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A Model of Delirium

A multifactorial syndrome that arises from an interrelationship

between

Predisposing factors

 a patient’s underlying

vulnerability

AND

Precipitating factors

 noxious insults

Slide20

Predisposing Factors

Baseline cognitive impairment

2.5 fold increased risk of delirium in dementia patients

25-31% of delirious patients have underlying dementia

Medical comorbidities:

Any medical illness

Visual impairment

Hearing impairment

Functional impairment

Depression

Advanced age

History of

EtOH

abuse

Male gender

Slide21

Precipitating Factors

Medications (see next slide)

Bedrest

Indwelling bladder catheters

Physical restraints

Iatrogenic events

Uncontrolled pain

Fluid/electrolyte abnormalities

Infections

Medical illnesses

Urinary retention and

faecal

impaction

ETOH/drug withdrawal

Environmental influences

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Medication Related

Precipitating Factors

Anticholinergics

Opiates

Benzodiazepines

Corticosteriods

Alcohol withdrawal

Sedative-hypnotic drug withdrawal

Any newly prescribed medication

Over the counter (OTC) “home remedies,” especially those with anticholinergic effects (NSAIDS, nasal sprays, cold and flu meds)

Addition of 3 newly prescribed

medications

Slide23

Important Exclusions

Wernicke’sHypoxia

Hypoglycemia

Hypertensive encephalopathy

Meningitis/encephalitis

Poisoning

Anticholinergic psychosis

Subdural hematoma

Septicemia

Subacute bacterial endocarditis

Hepatic or renal failure

Thyrotoxicosis/myxoedema

Delirium tremens

Complex partial seizures

Slide24

Delirium History

When did the change in mental status begin?

Does the condition change over a 24-hour period?

Is there a change in the person’s sleep patterns?

What specific thought problems have been noticed?

Is there a history of mental illness or similar thought disturbance?

Has there been a sudden decline in physical function or a new onset of falls

?

Any recent changes to medications?

Query

family or collateral source from prior setting as to ‘what is normal’ for this

patient – sometimes you can find something simple and reversible!

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Delirium “Work U

p”

REMEMBER THAT DELIRIUM IS A MEDICAL EMERGENCY!!

IT IS IMPORTANT TO DO A PHYSICAL EXAMINATION THAT

INCLUDES

Neurological examination

Hydration and nutritional status

Evidence of sepsis

Evidence of alcohol abuse and/or withdrawal

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Key to Effective Management

Examine

for signs of:

Hypoxia

Volume depletion/overload

Cardiovascular injury

Metabolic encephalopathy

Alcohol withdrawal

Hypo- or hyperthermia

New onset incontinence

Urinary retention or

faecal

impaction

Slide27

Key to E

ffective Management

Review

medication

list!

Baseline laboratory studies:

Urinalysis

Blood

Investigations – FBC / U&Es / LFTs / TFT / ESR / CRP / Glucose /

ABGs / blood Cultures

Further diagnostic testing (based on exam):

Neuroimaging

ECG

Chest X-Ray

EEG – (When difficult to differentiate delirium from acute psychotic state

)

EEG

typically shows slowing of alpha rhythms, the emergence of theta waves, and eventually bilaterally symmetrical predominantly

frontal delta waves

Slide28

Non-Pharmacological Approaches

Presence of family members

Interpersonal contact and reorientation

Provide visual and hearing aids

Remove indwelling devices: i.e. Foley catheters

Mobilize patient

early

A quiet environment with low-level lighting

Uninterrupted sleep

Slide29

Delirium: Maximising Cognition

Re-orientating strategies

Inclusion of orienting facts in normal conversation

Discussion of current events

Discussion of specific interests

Structured reminiscence

Word games

Cognitive stimulation

Slide30

Management:

Hyperactive Delirium

Use drugs

only if absolutely necessary

: harm, interruption of medical care

First line agent:

haloperidol

(IV, IM, or PO)

For mild delirium:

Oral dose: 0.25-0.5 mg

IV/IM dose: 0.125-0.25 mg

For severe delirium:

0.5-1 mg

IV/IM

Patient will likely need

2-5 mg total

as a loading dose

May

use

olanzapine

and risperidone

(Lonergan E et al. Cochrane Database Syst Rev. 2007 Apr 18; (2

))

NB

– check NICE guideline (olanzapine or haloperidol)

Slide31

Haloperidol

WHAT SIDE EFFECTS WOULD YOU MONITOR FOR?

QT prolongation

Risk of ventricular arrhythmias

Consider getting a baseline

ECG

This medication is ‘off label’ without an ECG

Extrapyramidal side effects

Acute dystonia

Parkinsonism

Akathisia

Neuroleptic malignant syndrome

Orthostatic hypotension (falls)

Over-sedation

Slide32

Lorazepam

Second line agent

Reserve

for

:

Sedative and ETOH withdrawal

Parkinson’s Disease

Neuroleptic Malignant

Syndrome

Slide33

AVOID RESTRAINTS AT ALL

COSTSMeasure of LAST(!!!) resort

Slide34

Outcome

Poor prognosis in the

elderly

Independently associated with:

Increased functional disability

Increased length of hospital stay

Greater likelihood of admission to long-term care institution

Increased mortality

1 month: 16%

6 months: 26

%

Symptoms

often persist 6 months

later

Slide35

Discussion Point

Symptoms often persists 6 months

later or even longer

This sometimes presents a challenge from a service perspective

Medical Ward versus Psychiatric Ward

Any thoughts?

Slide36

Summary

A multifactorial syndrome: predisposing vulnerability and precipitating insultsDelirium can be diagnosed with high sensitivity and specificity using the CAM

Prevention should be our goal

If delirium occurs, treat the underlying causes

Always try

nonpharmacological

approaches

first

Use low dose antipsychotics in severe cases

Slide37

Selected references

Delirium: prevention, diagnosis and management, NICE guidelines [CG103]

O’Connell

, H., Kennelly, S. P., Cullen, W., & Meagher, D. J. (2014). Managing delirium in everyday practice: towards cognitive-friendly hospitals. Advances in psychiatric treatment, 20(6), 380-389

.

Young

, J., & Inouye, S. K. (2007). Delirium in older people. BMJ: British Medical Journal, 842-846.

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Please provide feedback/suggestions on this presentation to the module lead

mark.worthington@lancashirecare.nhs.uk

Slide39

Old Age Module

MCQs

Which of the following is most common in delirium?

A. Hallucinations

B. Sleep-wake cycle disturbed

C. Labile mood

D. Increased motor activity

E. Delusions

Slide40

Old Age Module

MCQs

Which of the following is most common in delirium?

A. Hallucinations

B.

Sleep-wake cycle disturbed

C. Labile mood

D. Increased motor activity

E. Delusions

Slide41

Old Age Module

MCQs

What % of patients with delirium go onto develop dementia:

5

%

10-25

%

25-45

%

1

%

90

%

Slide42

Old Age Module

MCQs

What % of patients with delirium go onto develop dementia:

5

%

10-25

%

25-45

%

1

%

90

%

Slide43

Old Age Module

MCQs

Which of the following is not a risk factor for delirium:

Recent

surgery

Poor

sight

Terminal

illness

Pre-existing

memory problems

Intellectual disability

Slide44

Old Age Module

MCQs

Which of the following is not a risk factor for delirium:

Recent

surgery

Poor

sight

Terminal

illness

Pre-existing

memory problems

Intellectual disability

Slide45

Old Age Module

MCQs

Which is a clinical feature common to both dementia and delirium:

Rapid

onset

Global

cognitive impairment

Clouding of

consciousness

Clear

consciousness

Gradual

onset over 6 months

Slide46

Old Age Module

MCQs

Which is a clinical feature common to both dementia and delirium:

Rapid

onset

Global

cognitive impairment

Clouding of

consciousness

Clear

consciousness

Gradual

onset over 6 months

Slide47

Old Age Module

MCQs

Which assessment rating tool does

NICE recommend

using to assess for delirium:

MOCA

CAM

MMSE

ACEIII

DAS21

Slide48

Old Age Module

MCQs

Which assessment rating tool does

NICE recommend

using to assess for delirium:

MOCA

CAM

MMSE

ACEIII

DAS21

Slide49

Old Age Module

Any Questions?Thank you